HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 162 ABBOTT STREET 1/31/2022 Commonwealth of Massachusetts
City/Town of
z System Pumping Record •
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe*used, but the
information,must be substantially the same as that provided here. Before using.this form,check with you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Left/Right front of house, Left]Right rear of hous L /right side of house, Left
Right side of building, Left/Right front of building, Left T _- ar of buift/wer deck
on the only
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key to move your Add gss AA � �� /
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use key the return City/Town ,�" lJ ,�L�l State ( RN Zip Code
2. System Owner: �FPgR MEj�TER
Name
rzom `�
Address(if different from location)
MA
Cityfrown State Zip Code
4, 7(52
TelepForve Number
B. Pumping Record _
1. Date of Pumping Date 2. Quantity Pumped: Gallons —
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes, ]/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition f component pumped:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Lo ion where contents were disposed:
L Lowell Waste Water
Signature Date